Tanning Bed Use Among Adolescents: Hw the Current Approaches Aimed at Reducing This Behavior Have Failed to Apply Social Science Theories – Rachael B

Introduction

Skin cancer is currently the most commonly diagnosed cancer in the United States, yet it is largely a preventable disease. There are three main categories of skin cancer: basal cell and squamous cell carcinomas, which are not tracked by cancer registries, non-epithelial, and melanomas. Melanomas are the most deadly type of skin cancer. According to the Centers for Disease Control (CDC), in 2007 there were 58,094 people in the United States diagnosed with melanomas of the skin and 8,461 people who died from the disease (1). In 2010, it was expected that there would be 74, 010 new cases of skin cancer (excluding basal and squamous cell), 68,130 of which would be melanomas, and 11,790 deaths from skin cancer, 8,700 of which would be from melanomas (2-4).

Not only is melanoma a significant health problem, but it is also a growing health concern. Over the past several decades, melanoma incidence has increased, especially among women ages 20 to 39. According to the CDC, the U.S. trends in incidence of melanoma show significant increases of 3.1% per year from 1986 to 2006 for men, and 3.0% per year from 1993 to 2006 for women. Melanoma mortality rates have also increased (5).

A primary cause of skin cancer is exposure to UV light. It is thought that approximately 65-90% of melanomas as caused by UV light exposure (6). The International Agency for Research on Cancer (IARC) classifies UV radiation as a Group 1 carcinogen, implying that it is known to cause cancer (7). While for many, primary exposure to UV light occurs through outdoor sunlight, there are also a substantial number of individuals who use artificial light, primarily via tanning beds, to intentionally expose their skin to this danger. Tanning devices such as tanning beds are actually also now classified by IARC in the Group 1 carcinogenic category, the same category that contains cigarettes and plutonium. Many studies over the years have linked tanning bed use to significantly increased risk for skin cancer (8).

The indoor tanning industry has grown tremendously over the past several decades, despite the known health risks. It is reported that on an average day, more than one million Americans will use tanning salons, and in one year, more than 2.3 million teenagers will tan indoors (9-10). Adolescents are a particularly vulnerable group to the risks of tanning. For many people, the majority of extreme exposure to UV light occurs during their adolescent years, and such exposure during one’s youth can lead to skin cancer years up the road.

According to 2005 data from CDC’s Morbidity and Mortality Weekly Report (MMR), 8.7% of teens ages 14 to 17 had used indoor tanning devices, and that percent significantly increased with age, so while only 3% of 14 year-olds reporting indoor tanning, approximately 18% of 17 year-olds reported engaging in the behavior (12). According to MMR’s 2009 Youth Risk Behavior Surveillance data, nationwide, 15.6% of high school students reported having used an indoor tanning device at least once within the prior 12 months (with a prevalence of 25.4% among females and 6.7% among males). Prevalence of indoor tanning also increased with increasing school year: it ranged from 16% among ninth-grade females to 33.7% among twelfth-grade females. Similar trends were seen with the male students (13).

It is clear from this data that a substantial number of adolescents are currently engaging in indoor tanning, and the numbers are only increasing with time. The current approaches aimed at reducing tanning bed use among minors are not working, and this should be considered a major public health concern. Issues that are leading to this failure include the lack of emphasis on parental opinions of indoor tanning, the lack of focus on social behavior, and the use of statistics rather than stories to relay the message that indoor tanning is dangerous.

The Flaws of Current Approaches

Part 1: Parents Need Training, Too

The most common approach that is currently being used to limit minors’ tanning bed use is state law requiring those under the age of 18 to obtain parental consent. There are currently 31 states which require parental consent for minors to use tanning beds, the majority of which require the consent be given in-person (14). Of these 31 states, only 11 have any age limits at all (most don’t allow those less than 14 years old to tan, regardless of parental consent). The rationale for this measure has been that parents will have a better understanding of the health risks than will their children, and thus will deny their children permission to use tanning beds.

While requiring parental consent could be considered a step in the right direction, what this approach does not consider are parental beliefs and parental perceptions surrounding indoor tanning. In a recent study being published this May in the American Journal of Public Health, investigators gathered information on indoor tanning use among adolescents ages 14 to 17 in one-hundred U.S. cities. They found that adolescent use of tanning beds is not significantly associated with residing in a state where youth-access legislation is in place (11). This means that adolescents living in states where parental consent is required are tanning just as frequently as those living in states where parental consent is not required. Thus, the laws requiring parental consent are clearly not serving their intended purpose of decreasing tanning bed use among teenagers.

In their approach, states fail to address social science theories which demonstrate that many parents who may currently use or have previously used tanning beds, or perhaps just spend a lot in time in the sun, are likely to believe or rationalize that tanning beds do not pose a significant threat to their child’s health. When a parent regularly tans, whether it be just in the summer months or year round, at the beach or at a tanning salon, that parent is not likely to either understand or acknowledge the serious harm to which they are exposing themselves. Perhaps the parent has come up with justifications for why it is not unhealthy for them to tan, or perhaps the benefit of looking tan outweighs their concerns for any potential adverse health outcomes. When the parents cannot rationally understand and acknowledge the risks of this behavior, and in doing so disengage from the behavior, how are they expected to actively prevent their children from behaving in such a way?

Cognitive Dissidence Theory states that people will behave in ways which correspond to their beliefs. If a person’s behavior and beliefs are at odds with one another, then that person will either change their behavior to match their beliefs or modify their beliefs to coincide with their behavior (15). It is a theory that explains how people try to make sense out of their behaviors and beliefs (16). Simply by asking parents to give their children consent to engage in a behavior which they do not truly consider dangerous will not result in decreased use of tanning beds among teenagers.

Many believe that federal or state law should completely ban tanning bed use for those under 18. While this would be the most effective way to address the issue, at this point in time, no such laws are in place. Without a change in the law itself, the only way to make these new laws requiring parental consent serve their intended purpose is to reduce the number of parents willing to give their children consent to use tanning beds. In order to do this, we must modify the parents’ attitudes and beliefs about indoor tanning. The best way to accomplish this is to create a movement that the parents can involve themselves with, a movement which will lead to a change in their attitudes towards indoor tanning, and will subsequently lead to a change in their behavior.

Part 2: Lack of Focus on Social Behavior

Public health campaigns aimed at reducing tanning among adolescents primarily approach the issue at the individual level. The CDC has published guidelines for school programs related to skin cancer prevention; however, their recommendations primarily involve changing individual behavior. Tanning-related behaviors such as wearing sunglasses and hats, as well as regularly applying sunscreen are emphasized (17). With such a focus on individual behavior, not enough attention is paid to how one’s social environment affects one’s behaviors. And this is especially important for adolescents, who are greatly impacted by their social networks.

A social science theory which could be used to tie in social factors to reducing the use of tanning beds is the Social Network Theory, which has been largely ignored in this setting. The Social Network Theory is a group level model which is based on the idea that behavior spreads through social networks. This theory states that the behavior of the people in one’s social network is the primary determinant of how that person will behave. Individual’s actions are viewed as interdependent rather than independent (18). Personal relationships become channels for not only the transfer of information but also for the encouragement to continue or disengage in certain behaviors.

Much research has been done on how social networks affect health-related behaviors. One study, published in 2008, investigated the dynamics of smoking within social networks. In the studied population, the researchers found that there existed clusters of smokers and nonsmokers, and that smoking cessation appeared to be related to social networks. Their results indicated that social groups of people were quitting smoking at the same time (19). These results have significant implications for public health interventions. By focusing on getting people within the same social networks to quite unhealthy behaviors together, these disengagements in behaviors will likely spread through that network and possibly even on to other linked networks.

Part 3: Statistics Won’t Cut It

It is well known that many people have a difficult time relating to numbers and statistics, but just how difficult a time do people have understanding health risks when presented as statistics? The Law of Small Numbers suggests that people have a very difficult time interpreting the significance of numbers. Specifically, it suggests that judgmental bias occurs as a result of people assuming that a small sample is representative of a larger sample. People tend to make generalizations based on insufficient data (20). As applied to public health, this theory is relevant because it demonstrates the difficult time that people generally have understanding statistics, and thus their perception of risks from unhealthy behaviors may be distorted.

The CDC has series of podcasts available on their website related to a range of health topics. The podcasts related to indoor tanning primarily use statistics to convey the message that indoor tanning is potentially harmful to one’s health. One podcast states that frequent indoor tanning leads to 2.5 to 3 times increased risk for melanoma (21). Adolescents will have a difficult time interpreting how this statistic applies to their personal risk for the disease. It should also be noted that since no definition for what is considered ‘frequent’ tanning is defined in the podcast, adolescents are likely to consider their own tanning bed use as less than frequent.

The American Academy of Dermatology (AAD) also makes use of statistics in an attempt to demonstrate the dangers of indoor tanning. The AAD has created a series of skin cancer prevention posters aimed at reducing indoor tanning among adolescents. A few of the posters note that one American dies of melanoma almost every hour. Can adolescents (or their parents for that matter) really relate to a fact such as this? Do they understand the health implications of such a statistic?

Rather than using statistics to present the facts to adolescents, which is common among current campaigns, instead we must tell stories that provide familiarity and context. We must tell stories that adolescents can relate to and use these stories as a means to convey the dangers of indoor tanning. The AAD does actually have one young melanoma victim that they use in their campaigns—a woman who had frequented tanning booths as a teenager only to be diagnosed with melanoma at the age of 21. After years of treatment, she finally succumbed to the disease at the age of 29. While this is certainly a compelling story, the AAD does not use the story in a way in which it will have the most impact on adolescent indoor tanning. They have two posters which contain quotes from the woman’s family members, but each of these posters also contains the statistic noted above, regarding one American dying of melanoma almost every hour. They also have a short video clip of the victim’s mother giving a brief account of her story, and in this clip, they end with another statistic about the increased risk of melanoma from indoor tanning. While this story could be used as part of an effective campaign, the current way in which it is being used has many flaws.

New Approaches to the Battle Against Adolescent Indoor Tanning

Part 1: Educate and Sell a Movement to the Parents

Following the arguments made above, it is clear that new approaches are needed in order to reduce tanning bed use among adolescents. One major component of a new approach must address parental views related to the health risks of tanning. In order to change parents’ behavior and encourage them to deny their children the consent to tan indoors, we must sell a movement which involves first educating the parents, then modifying their beliefs about indoor tanning, and in doing so get them to commit to behaving in a way which reflects their new beliefs.

An internet-based program could be developed to create a social network of parents who are dedicated to preventing their teenage children from getting skin cancer. Using the principals of the Cognitive Dissidence Theory, the program must first educate the parents on the dangers of tanning beds, thereby encouraging changes in their attitudes so that instead of thinking of indoor tanning as a social activity that boosts their teenager’s self-confidence, they will think of it as a dangerous activity with the potential for serious adverse health effects. Parents who commit to being part of the movement, especially those who stay actively involved with it, will be more likely to tell their children “no” when it comes to indoor tanning.

Not only will the program need to educate on health risks, but it will also need to shift the parent’s perceptions of tans as looking healthy to tans as being indicators of damaged skin. Thinking of tans in a negative light will make it easier to avoid the behaviors that lead to tans. Emphasis could be place on alternative means to look and feel healthier, such as increased physical fitness, the use of make-up, or different hair styles. Sunless tanning, such as tanning lotions or stray tans, could even be suggested for those that are determined to maintain a ‘bronzed’ appearance. Ultimately, it would add to the benefits of the program if the parents were to pass on their new found knowledge and beliefs to their children. Not only would this impact their child’s tanning habits, but perhaps it would also end up having a positive impact on their own skin protection beliefs, thereby serving a dual purpose.

Part 2: Refocus on Social Networks

Rather than focusing on individual behavior, the new approaches towards reducing tanning bed use among adolescents must involve shifting the focus to adolescent social groups. Campaigns aimed at addressing this public health issue could target social networks through high schools, community centers, religious centers or even local malls. The idea would be to target groups of teenagers rather than individual teens, and in doing so, change the behaviors of entire adolescent social groups at once.

According to the Social Network Theory, people will behave in ways which coincide with the behavior of those in their social networks. If we can get groups of adolescents to commit to eliminating their use of tanning beds, this behavior could spread throughout their social network and later on to other linked networks. A campaign involving public service announcements and group information sessions could address large groups of teenagers at once. On key aspect of the campaign should involve having fellow adolescents serve as the spokespeople, as they will better be able to effectively communicate the message than will adults. Another key component would be specifically targeting locations where teens frequent as a means to reach as many people as possible with each campaign component.

As studies have suggested, not only do negative behaviors spread through social networks, but so do positive ones. Once the behavior of avoiding sunless tanning is adopted, that will become the new norm, and once teens begin to see their friends skipping the tanning salons, they will be far more likely to skip it themselves.

Part 3: Use Stories, Not Statistics

As described above, people do not generally understand the implications of statistics. For this reason, it is typically more effective to use stories to adequately relay messages regarding public health issues. The Canadian Dermatology Association (CDA) has a campaign named “Indoor Tanning is Out,” which does a nice job of using personal stories to relay messages concerning the dangers of indoor tanning (22). The current stories being used are those of six young women who were all frequent tanning bed users. Each of these young women was diagnosed with melanoma, at an age ranging from 18 to 35 years. Reading these women’s stories certainly makes one reconsider their views about participating in a behavior that could lead to cancer at such a young age. These are seemingly normal, average women, and teenagers might think that if this could happen to these women, it could happen to anyone, including themselves.

While the “Indoor Tanning is Out” campaign uses these stories very effectively, the video portion of their program is not nearly as effective, as it doesn’t actually include any of the narratives. A new, effective campaign could use the stories of young women such as the ones used in CDA’s campaign to reach adolescents via media advertising. Profiling the stories of young women with melanoma will make adolescents better able to relate and could serve to change their beliefs related to indoor tanning. If they see that people who were just like they were as teenagers could be affected, they may begin to believe that they too could get skin cancer as a result of using tanning beds.

While indoor tanning campaigns may be aimed at both male and female adolescents, the vast majority of young tanning bed users are female. The melanoma incidence rate is also quite higher among young females than among young males. According to the National Cancer Institute’s Surveillance Epidemiology and End Results, the 2006 to 2008 melanoma incidence among females ages 15 to 34 years was 37.8 per 100,000, while in the same time frame it was 19.4 per 100,000 for males of the same age range. Not only is the melanoma incidence rate higher for young females, but the incidence rate also significantly increased for females from the 1996-1998 to the 2006-2008 time period, while it decreased for males (2).

This data suggests that the most effective campaigns may be those targeting the adolescent female population. When considering whose stories you want to tell in a campaign such as this, telling the stories of young women as opposed to young men, such as the CDA campaign does, will likely have the biggest impact. With melanoma incidence rates at the level that they are and tanning bed use so frequent among female adolescents, one could assume that there are many young women in the United States who have experienced melanoma diagnoses and it is very possible that they were frequent tanning bed users as well. These stories could go a long way in making adolescents think twice before hopping into a tanning bed.

Conclusion

Tanning bed use among adolescents is common, especially among sixteen and seventeen-year-old females. While in many societies this is considered the normal behavior by the teens as well as by their parents, there are serious health risks associated with tanning bed use, specifically the occurrence of melanoma. Current approaches aimed at reducing tanning bed use among adolescents include state laws requiring parental consent for those under 18, targeting changes in individual behavior, and using epidemiological statistics to explain the risks associated with the behavior. The common problem among these approaches is that they fail to apply social science theories and therefore have substantial flaws which will result in their failure to reduce teenage tanning bed use.

New approaches must incorporate social science theories in order to be effective. Cognitive Dissidence Theory, Social Network Theory and the Law of Small Numbers are among the theories which could be applied to interventions aimed at addressing this public health issue. Changing the attitudes and believes, and consequently the behavior of parents who consent to their children using tanning beds is one important tactic. Next, implementing campaigns targeted at influencing teen behavior through social networks is a must. Finally, using stories rather than statistics will be a much more effective means to make an impact on adolescent tanning behaviors.

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